The Graduate Practitioner orientation

on Tuberculosis
Venue: Civil Surgeon Office, Faridpur
Date:28
th
January 2014
Organized by: Civil Surgeon office , Faridpur & NTP.
Presented by:
Dr Karuna Kanta Dey, Consultant. Damien Foundation.
Tuberculosis
Definition
Tuberculosis is an infectious disease, caused by
Mycobacterium tuberculosis or AFB or Tubercle bacilli

Mode of Spread of Tuberculosis bacilli
The bacilli usually enter the body by inhalation through
the lungs through coughing, sneezing and spitting and
spread to other parts of the body via the blood stream, the
lymphatic system, or through direct extension to other
organs
In 1882, Robert Koch
discovered a staining technique
that enabled him to see
Mycobacterium
tuberculosis.
What excited the world was the
accompanying certainty
that now the fight
against humanity's
deadliest enemy
could really begin.

in 1993,
the World Health
Organization (WHO)
declared TB a
"global emergency."


Still Now

Tuberculosis is the leading
infectious disease
cause of death
and
represents more than a quarter of
the world's preventable deaths.

Tuberculosis: Estimates in Bangladesh
ARTI: 2.14%
50% of adult population infected
Incidence rate all cases: 223 / 100 000 / yr
Incidence rate (New P+): 100/ 100 000 / yr
>300,000 New Sm+ PTB cases expected per year
70,000 estimated deaths due to TB every year
Ranks 6
th
on the list of 22 highest TB burden
countries

One TB death every 10 minutes
One New TB case every 2 minutes
8
TB High Burden Country: 5 in SEA-Region
1. India
2. China
3. Indonesia
4. South Africa
5. Nigeria
6. Bangladesh
7. Ethiopia
8. Pakistan
9. Philippines
10. DR Congo,
11. Russian Federation
12. Vietnam
13.Kenya
14. Tanzania
15. Uganda
16. Brazil
17. Mozambique
18. Thailand
19. Myanmar
20. Zimbabwe
21. Cambodia &
22. Afghanistan
TB Burden: Global Cases (all forms), 2012
80%
(SEAR = 38%)
20%
All Other
Countries
1. India (22%)
2. China
3. Indonesia (7%)
4. Nigeria
5. South Africa
6. Bangladesh (4%)
7. Pakistan
8. Ethiopia
9. Philippines
10. Kenya
11. DR Congo
12. Russia Federation
13. Vietnam
Top 22
Countries
harbor 80%
of Global TB
burden
NTP Bangladesh: Goals & Objectives
Goal: to reduce the incidence of TB until it is no longer a public health
problem, by diagnosing and treating effectively as many TB patients as
possible, especially those whose sputum is smear-positive (Infectious
cases)
Objectives: to increase
40%
85%
10%
70%
1991 2005 1991 2005
Cure Rate
Detection Rate
Detection of New Smear Positive Case: 72% National average
during 2011
Treatment success rate: 92%
40%
85%
92%
10%
70%
72%
1991 2005 2010 1991 2005 2011
Cure Rate
Detection
Rate
Source is Smear positive TB

One person with infectious TB
infects between 10 and 15 people on
average in one year.

Transmission of infection
Transmission occurs by airborne
spread of infectious droplets. The
source is sputum smear-positive TB
Coughing produces tiny infectious
droplets (droplet nuclei). One cough
can produce 3,000 droplet nuclei.
Transmission generally occurs
indoors, where droplet nuclei can stay
in the air for a long time.

Contact with TB Bacilli
90% NOT SICK
WITH TB
10% DEVELOP
TB

Immediately
5%

Later in
Life 5%
Prevalence of different types of TB
In Endemic countries
EP
15%


Pulmonary
85%







Sm ve; 1/3
Sm +ve; 2/3
WHY SPUTUM
MICROSCOPY?
Suspect PTB:
Cough for 3 weeks or more
Haemoptysis of any duration
Low grade Fever (evening)
Loss of weight/wasting
Chest pain, dysponea
Refer suspects/cases to UHC/CDC for sputum
Examination (Diagnosis) & Treatment.
Suspects: Cough 3 weeks or more

3 X Sputum for AFB

If 2/3
+ve
If 1 +ve,
X-Ray &
evaluation

If Negative, Broad Spectrum
Antibiotic 10-14 days
(Exclude Quinolones)
If symptoms persist,
repeat AFB smears, X-Ray
If consistent with TB
Anti-TB Treatment





























Diagnostic Algorithm
85%
96%
100%
1st Slide 2nd Slide 3rd Slide
C
u
m
u
l
a
t
i
v
e

P
o
s
i
t
i
v
i
t
y

(
%
)
TB diagnosis: Three Sputum Smears are Optimal
Note: 1998 data from a survey on gender differences in TB case finding and holding performed
jointly by government and NGOs in 59 upazilas (unpublished)
Role of Chest X-ray
No chest X-ray pattern is absolutely typical
of TB
10-15% of culture-positive TB patients not
diagnosed by X-ray
40% of patients diagnosed as having TB on
the basis of x-ray alone do not have active
TB


X-ray is unreliable for diagnosing and
monitoring treatment of tuberculosis
50%
98%
0
20
40
60
80
100
AFB Microscopy X-ray
Microscopy is a more specific
test than X-ray for TB diagnosis
Specificity
NTP Regimens:
Treatment
Category
Present Regimen Indication
Cat 1 2EHRZ/4HR

All New cases
Cat 2
2SEHRZ1EHRZ/5EHR

NOT NEW
cases
Types of Patients
New: Patients who never took treatment
before or took treatment <1 Month
Not New: Patients who took treatment
before for 1 month or more
- Relapse
- Failure
- Default
- Other
23
DOTS Strategy: 5 basic components
to ensure necessary political
and financial support
cost effective diagnosis:
focus on smear-positives,
passive case finding,
direct microscopy
of sputum for AFB
effective treatment of TB:
short-course, standardized,
multi-drug, directly
observed treatment (DOT)
Cure is the best prevention
to ensure uninterrupted
supply of drugs and lab
reagents
to follow the patient and monitor
the progress of treatment;
standard forms, cards and registers;
cohort analysis
1. Government Commitment
2. Case Detection through sputum microscopy
3. Short-Course Chemotherapy
4. Supply System
5. Recording and Reporting

24
25%
95%
60%
50%
2%
10%
25%
2%
30%
No Treatment (after 5
years)
DOTS Non-DOTS
Cured
Dead
Chronic
Tuberculosis: outcome in different
conditions
Likely
MDR
Prevention & Control
Early Diagnosis = Reduced time of transmission
Prompt, Effective Treatment = Reduced time of
transmission & Elimination of source of infection
= No transmission = Reduced burden of disease
Improving housing conditions allowing proper
ventilation & sunlight = reduced bacterial
concentration in the air, bacteria killed by sunlight
= reduced infection
Improved Immunity through balanced diet (Poor
people, can they have balanced diet?)
Does BCG prevent TB infection or
TB Disease?
BCG contains live attenuated TB bacilli
BCG vaccination means artificially infecting the
child with an aim to produce antibody against TB
bacilli
If TB bacilli is inhaled, immune cells capture the
bacilli in lung & thus prevent from rapid spread
within & outside the lungs. So no TB meningitis
& no Milliary TB (the two dreadful TB in child)
In high endemic countries BCG is not given to
adults because they are already exposed to TB
bacilli.

Different ACSM Activities Carried out in 2013:

Name of the Activities
2013
Planned Done
Session Participants Session Participants
TB Club Meeting 319 7975 319 8096
Orientation of Non Graduate PPs 76 1900 76 1898
GP Orientation 23 460 23 355
Orientation on TB & HIV 16 400 16 396
Women Group Orientation 4 100 4 100
Retraining of Multipurpose Health Staff of
SR
2 40 2 40
Training on MDR TB Management 1 20 1 19
Folksong 24 0 24 0
Observe World TB Day 27 0 27 0
Trends of TB suspect & New P+VE Case / 100000 population & positivity rate since 2009 to 2013
753
663
630
620 657
38
35
33 35
31
5.36
5.8 5.65
5.93
5.13
1
10
100
1000
Suspect New P(+) Case Posit. Rate
Suspect 753 663 630 620 657
New P(+) Case 38 35 33 35 31
Posit. Rate 5.36 5.8 5.65 5.93 5.13
2009 2010 2011 2012 2013

TB Case Notification/100000 pop. (All Forms) Since 2009-2013

31
35
33
35
38
3
3
4
4
5
11
9
10
10
11
16 16 16
15
14
65 65
64
66
67
0
10
20
30
40
50
60
70
80
P+ New P+ Re P - New EP New All Forms
P+ New 38 35 33 35 31
P+ Re 5 4 4 3 3
P - New 11 10 10 9 11
EP New 14 15 16 16 16
All Forms 67 66 65 65 64
2009 2010 2011 2012 2013
Trend of Died , Default & Failure Rate Among New P(+)ve Cases Since: 2008-2012
2%
4% 4%
88% 87%
89%
89%
91%
2%
3%
3%
2%
4%
4%
3%
4%
3%
3%
4%
3%
1%
10%
100%
Cured Default Failure Died
Cured 88% 87% 89% 89% 91%
Default 2% 3% 3% 2% 2%
Failure 4% 4% 3% 4% 3%
Died 3% 4% 3% 4% 4%
2008 2009 2010 2011 2012
Chemo prophylaxis

No of child eligible for chemo during 2013

653

No. of child received chemo during 2013

562

No. of child received chemo in 2012

% completed chemo of cohort 2012

406

369
(91%)
Global MDR-TB situation
Estimated MDR-TB cases: 0.5 million
27 countries accounts 85% of global cases
Top 5 countries: India (131000), China
(112000), Russian Federation (43000),
South Africa (16000) & Bangladesh
(15000)
MDR-TB in Bangladesh
No national survey/surveillance data

WHO 2012: MDR TB among New Case 2.1%,
Among Retreatment 28%.

Difficult to diagnose & treat; less effective,
costly, extra burden on health system;
Preventable (Results from inadequate
treatment at NTP and/or private level).
DF MDR TB project
Trial project TO DEVELOP a cost effective
standard MDR TB treatment regimen

Globally NO Randomized Controlled Clinical
Trial on treatment of MDR TB (limitations)

Current recommendations (WHO regimen)
based on expert opinion
Information on MDR TB of Greater Faridpur.
Year Total started Cured Died Default Failure
2007 28 26 2 0 0
2008 17 14 1 2 0
2009 29 25 3 1 0
2010 17 14 2 0 1
2011 22 18 0 2 2
2012 17 17 0 0 0
2013 24 (01 XDR)
Financial investigation support (X-ray, FNAC / Biopsy, MDR
and other test) for P-ve, EP, MDR & Child TB Suspect
(The investigations must be advised by Doctor)
Investigation Description Amount
X-ray & other
Investigation &
travel fare
1500/
FNAC, Biopsy &
other
Investigation &
travel fare

3000/
MDR TB & other
Investigation &
travel fare

3000/
38
Together we can
Make it happen !
Please Join us to
make Bangladesh a
TB free country with
your expertise

Our Appeal
Thanks for your kind
Attention